Medicare Medicaid Coordinated Plan/idaho Medicaid Plus Overview
Blue Cross of Idaho offers a Medicare Medicaid Coordinated Plan in select service areas called the True Blue Special Needs Plan. Members must have full Medicare and Medicaid benefits to enroll in this plan and be over the age of 21.
November 1, 2018, Idaho Medicaid Plus became available in Twin Falls County. April 1, 2019, it was also offered in Bannock, Bingham, and Bonneville counties. Additionally, on June 1, 2019 Idaho Medicaid Plus became available in Bonner, Kootenai, and Nez Perce counties. August 1, 2019 the plan expanded to include Ada and Canyon counties. Plan members have the option of selecting the MMCP plan or the Idaho Medicaid Plus plan from Blue Cross of Idaho or Molina Healthcare of Idaho.
Idaho Medicaid Plus is for dually eligible individuals who have not selected a MMCP plan and covers all medically necessary Medicaid benefits, including:
- Hospital costs after Medicare payment
- Medical costs after Medicare payment
- Behavioral Health, including Community Based Rehabilitation Services
- Nursing home after Medicare payment
- Aged & Disabled Waiver
Idaho Department of Health and Welfare FAQS.
Select Provider Packet if you need to add demographic information, or wish to request a contract to become a provider for either plan.
Many of the tools resources made available to MMCP or Idaho Medicaid Plus providers require a secure login. If you do not have a secure login, please register above and follow the prompts.
Appeals And Fair Hearings
Medicaid estate recovery is the process through which each state recovers the costs of medical services it has paid from the estate of the person who received those services. The Medicaid estate recovery program impacts two groups of people receiving Medicaid benefits:
- Anyone over the age of 55 who has received Medicaid assistance, and
- Anyone who is permanently institutionalized and has received Medicaid assistance, regardless of age.
The estate recovery program may collect money from the estate of a deceased Medicaid recipient as repayment for any medical care services that were provided to the recipient and paid for by Medicaid, while the recipient was over 55 years of age, or permanently institutionalized, regardless of age.
Medical care includes a wide range of services, including nursing home and community based in-home care services. It also includes any hospital and prescription drug services the participant received while in a nursing home, or while receiving in-home care. Medical care also includes capitation payments to Medicaid-contracted health insurance companies or medical providers administering a defined package of benefits. The federal government directs states to pursue Medicaid estate recovery for these services.
- During the lifetime of the surviving spouse, regardless of where he or she lives.
- From a surviving child who is under age 21 years or is blind or permanently disabled , regardless of where he or she lives.
Use Local Care Coordinators
IDHW requires care coordinators to live in the same communities as enrollees so that they understand the environment, service providers, and transportation system. Having Idaho-based program care coordinators has been an important element of building trust among enrollees.
Take-away: To the extent possible, use locally based care coordinators who have a strong understanding of community resources and culture.
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Impetus For Pursuing An Integrated Care Program
In 2011, Idaho was among a group of states interested in pursuing a capitated model demonstration under the Centers for Medicare & Medicaid Services Financial Alignment Initiative. However, with only one health plan in the state, it was unable to move forward. At about the same time, Idahos legislature mandated that its state Medicaid agency improve service delivery for dually eligible beneficiaries.
After considering its options, the Idaho Department of Health and Welfare decided to use a Fully Integrated Dual Eligible Special Needs Plan a type of D-SNP as a platform to provide a high level of Medicare and Medicaid integration across the state. A FIDE SNP combines all of the services offered by Medicare with a prescription drug plan and all or most of a states Medicaid services, including LTSS. Like all other D-SNPs, a FIDE SNP must have a contract with the state Medicaid agency.
What Is An Hmo Pos
- An HMO POS is a Health Maintenance Organization with a Point of Service Option.
- An HMO POS is a Medicare Advantage Plan that is a Health Maintenance Organization with a more flexible network allowing Plan Members to seek care outside of the traditional HMO network under certain situations or for certain treatment.
- A Member will pay some additional fees for using the POS option.
- Idaho plans currently require you to use a specific hospital.
- Are only available in select counties.
- You continue to pay your Medicare part B premium and HMO POS premium.
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Qualifying For Both Medicare And Medicaid In Idaho
If you qualify for both Medicare and Medicaid, you can apply for Idahos Medicare/Medicaid Coordinated Alternative Benefit Plan. This option combines your Medicare and Medicaid benefits into one coordinated plan.
We have licensed agents who focus on Medicare coverage. If you or a loved one needs help selecting a Medicare Advantage or Medicare Supplement plan, or give us a call at 833-438-3676.
Eligibility Criteria For Idaho Medicaids Long Term Care Programs
To be eligible for Idaho Medicaid, a person has to meet certain financial and functional requirements. The financial requirements vary by the applicants marital status, if their spouse is also applying for Medicaid, and what program they are applying for Nursing Home / Institutional Medicaid, Home and Community Based Service Waivers or Aid to the Aged Blind and Disabled Medicaid.
Idaho Nursing Home Medicaid Eligibility Criteria
For married applicants with both spouses applying and both spouses living together in a nursing home, the 2022 asset limit for nursing home coverage through Idaho Medicaid is $3,000 combined. For married applicants who do not live together but are both applying for and receiving Medicaid assistance, the asset limit is $2,000 per spouse. The income limit for married couples with both spouses applying, no matter where they live, is $2,543 / month per spouse. For a married applicant with just one spouse applying, the 2022 asset limit is $2,000 for the applicant spouse and $137,400 for the non-applicant spouse, and the income limit is $2,543 / month for the applicant. The income of the non-applicant spouse is not counted.
Idaho Medicaid Home and Community Based Service Waivers Eligibility Criteria
Idaho Aid to the Aged Blind and Disabled Medicaid Eligibility Criteria
How Idaho Medicaid Counts the Home for Eligibility Purposes
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Therapy And Chiropractic Services
The Idaho Department of Health and Welfare will cover up to $2,040 of speech and physical therapy services per calendar year as well as another $2,040 for occupational therapy services. Chiropractic services are completely different and are limited to six visits per calendar year and only for manipulation of the spine when medically necessary. If you need more than six visits, your doctor will need to submit an authorization form proving your diagnosis and your need for treatment.
Idaho Medicaid Long Term Care Programs
Nursing Home / Institutional Medicaid
Idaho Medicaid will cover the cost of long-term care in a nursing home for eligible Idaho residents who require a Nursing Facility Level of Care. Nursing home coverage includes payment for room and board, as well as all necessary medical and non-medical goods and services. These can include skilled nursing care, physicians visits, prescription medication, medication management, mental health counseling, social activities and assistance with the Activities of Daily Living . Nursing Home Medicaid is an entitlement, which means that all eligible applicants are guaranteed by law to receive the benefits.
Some of the things Idaho Medicaid wont cover in a nursing home are a private room, specialized food, comfort items not considered routine , personal reading items, plants, flowers, and any care services not considered medically necessary.
Home and Community Based Service Waivers
Home and Community Based Service Waivers will pay for long-term care services and supports that help Idaho Medicaid recipients who require a Nursing Facility Level of Care remain, or return to, living in the community instead of residing in a nursing home. The HCBS Waiver available to Idaho residents is the states Aged and Disabled Waiver.
Like most HCBS Waivers, the A& D Waiver is not an entitlement. Instead, there are a limited number of enrollment spots , and once those spots are full, additional eligible applicants will be placed on a waiting list.
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State Demonstration To Integrate Care For Dual Eligible Individuals
The state planned to replace its existing voluntary Medicare-Medicaid Coordinated Plan with a Demonstration to Integrate Care for Dual Eligibles, effective January 1, 2014. Summary of Idaho Initiative to Integrate Care for Dual Eligibles, 10/2012)
On February 26, 2014, the state announced it will no longer participate in the Dual Eligible Financial Alignment Initiative Demonstration. Instead, Idaho will expand benefits under the existing voluntary Medicare-Medicaid Coordinated Plan . , 3/6/2014)
The state implemented dual eligible benefits under its MMCP on July 1, 2014. All persons age 21 and over who are eligible for Medicare and Medicaid can enroll in the MMCP. Medicare-Medicaid Coordinated Plan Stakeholder Update , 6/24/2014)
External Quality Review Reports
The Bureau of Long Term Care hosts an online Complaint Submission System. This system is available to all stakeholders and allows you to enter a complaint and provide us with all the details to help us investigate and resolve your concerns. Once the complaint is received, it is routed directly to our triage team and either Blue Cross of Idaho or Molina Healthcare of Idaho who are responsible to prioritize and manage all submitted complaints.
Blue Cross of Idaho Health Services, Inc.Program: MMCP and IMPlus
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Durable Medical Equipment And Home Health
Home Health consists of durable medical equipment/supplies, home aides, and home nurses. Idaho Medicaid limits Home Health to 100 visits per calendar year. Every visit must be medically necessary.
Members can receive coverage for reasonable and cost-effective durable medical equipment when considered necessary. The Idaho Medicaid program follows the federal Medicare criteria for durable medical equipment. Medicare considers items like hospital beds, wheelchairs, oxygen supplies, sleep apnea devices, and glucose monitors to be durable medical equipment.
Unitedhealthcare Senior Care Options Plan
UnitedHealthcare SCO is a Coordinated Care plan with a Medicare contract and a contract with the Commonwealth of Massachusetts Medicaid program. Enrollment in the plan depends on the plans contract renewal with Medicare. This plan is a voluntary program that is available to anyone 65 and older who qualifies for MassHealth Standard and Original Medicare. If you have MassHealth Standard, but you do not qualify for Original Medicare, you may still be eligible to enroll in our MassHealth Senior Care Option plan and receive all of your MassHealth benefits through our SCO program.
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Medicare Medicaid Coordinated Plan Prior Authorizations
Providers agree to accept Blue Cross of Idaho’s payment or appropriate denial for any item or service as payment in full and agrees to make no additional charge to the member except that is specifically allowed by Idaho Department of Health and Welfare as a member’s share of cost. The provider agrees not to bill the member for any services rendered unless specifically permitted to do so under cost-sharing rules and in the provider’s contract. The provider agrees not to bill Blue Cross of Idaho or the member if a third party payment is made to the provider unless the third party payment is less than the amount of the Blue Cross of Idaho payment plus any applicable member share of cost payment. The provider shall not refuse to furnish services on account of a third party’s potential liability for the services .
Before rendering services, contracting providers are responsible for ensuring the prior authorization is in place on behalf of the member for the services shown below.
Long Term Support Services
Prior authorization for long term support services including home and community-based services and long-term care are coordinated by the members care coordinator and reflect the services approved based on the members assessment and care plan.
Expanded Mental Health
Prior authorization for expanded mental health benefit are coordinated by the member’s care coordinator and reflect the services approved based on the member’s assessment and care plan.
Policy History
A New Approach To Integrating Care For Dually Eligible Beneficiaries: Idahos Medicare Medicaid Coordinated Plan
Individuals who are eligible for both Medicare and Medicaid often have complex health and social needs that are difficult to address in a fragmented, uncoordinated system of care. Like a growing number of states, Idaho wanted to serve dually eligible beneficiaries in a more integrated way. In 2014, the state launched a unique integrated care program, the Medicare Medicaid Coordinated Plan . Although the state does not have a Medicaid managed long-term services and supports program, this Dual Eligible Special Needs Plan -based model provides all Medicare services and most Medicaid services, including long-term services and supports . MMCP serves almost 30,000 dually eligible Idahoans and is a useful model for other states. With the support of the West Health Policy Center, the Center for Health Care Strategies looked at MMCPs structure, highlighting the programs early successes and lessons for other states.
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What Is A Ppo
Preferred Provider Organization Plans are among the most common and popular health plans right now for working Americans. In a PPO you:
- Dont need referrals to see a specialist provider out-of-network. You may need plan approval before you get certain services in and/or out-of-network.
- Can see any doctor or provider that accepts Medicare. However, if you go to doctors, hospitals, or other providers who are not part of the plan, you may pay more.
- You continue to pay your Medicare Part B premium and PPO premium.
- Co-payments apply to some services and some services.
Behavioral Health Managed Care
On October 31, 2014, the Idaho Statesman reported that the states shift to Medicaid managed care has resulted in behavioral health service cuts for beneficiaries, including cuts to community-based mental health and rehabilitation services. Since September 2013, when Idaho Medicaid implemented the Idaho Behavioral Health Plan and selected Optum to administer the plan using a managed care approach, Optum has cut community-based rehabilitation services by ten percent to focus on the use of more evidence-based practices. The IBHP provides services for children with serious emotional disturbance and adults with serious mental illness or serious and persistent mental illness, as well as any adults or children who manifest symptoms indicative of behavioral health issues.
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More Information On Mmcp
Idaho Medicaid has successfully implemented a mandatory managed care program, called Idaho Medicaid Plus .This program is for Dual Eligible participants who are 21 years of age or older and are eligible and enrolled in both Medicare and Enhanced Medicaid. The Department of Health and Welfare has partnered with Molina Healthcare of Idaho and Blue Cross of Idaho to administer IMPlus, which covers most Medicaid services and provides members with a care specialist. The care specialist serves as a single point of contact to assist participants in navigating their Medicaid services.
Idaho Medicaid Plus = Medicaid Benefits Only! With no changes to your Medicare coverage.
IMPlus is a mandatory program in the following counties: Twin Falls, Bonner, Bannock, Bonneville, Bingham, Kootenai, Nez Perce, Boise, Boundary, Cassia, Elmore, Fremont, Gem, Jefferson, Madison, Minidoka, Owyhee, Payette, Power, Ada, and Canyon.
IMPlus is open for voluntary enrollment in the following counties: Adams, Benewah, Clark, Gooding, Jerome, Latah, Shoshone, Valley, and Washington. Individuals in these counties can choose to opt-out of IMPlus. If a participant chooses to opt out of IMPlus, their services will remain with Idaho Medicaid.
IMPlus covers all medically necessary Medicaid benefits:
Idaho Medicaid Eligibility And Income Limits
To qualify for Medicaid in Idaho, you must either be under 19, a pregnant woman, an adult with a child under 19, blind, disabled, or over 65. You must also be a legal Idaho resident and must make less than the income limits listed below:
If you do not qualify for Medicaid and do not have other insurance but still have low income, you may qualify for covered pap tests and mammograms with the Department of Health and Welfares Womens Health Check Program.
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Presentation On Theme: Idaho Duals Programs Medicare Medicaid Coordinated Plan Presentation Transcript:
1 Idaho Duals Programs Medicare Medicaid Coordinated Plan 28,000 full dual eligible in Idaho around 400 new members each monthMedicare Medicaid Coordinated Plan Idaho Medicaid PlusDesigned for duals that do not enroll in MMCPMandatory enrollment auto-assignment will occur for members that do not select a Health PlanPilot program in one county live November 2018Target counties will include 20,000 members by September 2019Benefit package includes Medicaid behavioral health, skilled nursing facility, and home and community based services.Voluntary, opt-in enrollment structureOperated as a Fully Integrated Dual Eligible Special Needs Plan 4,000 enrolled in the MMCPAvailable in 22 of Idahos 44 countiesBenefit package includes Medicare A, B and D, in addition to Medicaid behavioral health, skilled nursing facility, and home and community based services.
Understand The Medicare Landscape And Its Language
While IDHW staff are well-versed in Medicaid, they had to learn about Medicare. Its terminology, regulations, processes, and timelines were new to them. In the beginning, they relied on their plans for guidance. Now, they have gathered a wider circle of experts and resources to help them recognize and tackle Medicare issues, and have often turned to the Medicare-Medicaid Coordination Office at CMS and its technical assistance contractors to answer questions.
Take-away: Develop expertise or identify resources to help decipher the Medicare policy landscape.
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